Quantitative Analysis of Challenges Encountered by UK Widening Participation Medical Students in Comparison With Their Non-Widening Participation Peers

OBJECTIVES Few studies have captured the experiences of widening participation (WP) medical students, and none have compared their experiences to their non-WP peers. This study aims to identify which challenges WP students are more likely to face. METHODS A 22-item questionnaire was distributed to medical students across all UK medical schools. Students were asked yes or no questions on whether they faced challenges in finances, socializing, physical and mental health, academic attainment, and COVID19-related teaching changes. RESULTS One-hundred seventy-six medical students from all year groups across the UK responded, with 97 students from a WP background. WP students were significantly more likely to have their personal background impacting their mental health (OR = 2.65, WP  =  0.002), more than twice as likely to feel that their job impacted their studies (OR = 2.53, P ≤.05), more likely to feel limited by their financial situation (OR = 2.29, P≤.05) and to receive support from student finance (OR = 2.08, P < .05). CONCLUSION WP students were more likely to face challenges in mental health and finances in medical school compared to their peers. These findings, further informed by qualitative insights can aid in advancing equity in medical training.


Introduction
Widening participation (WP) refers to the process of encouraging underrepresented groups from different socioeconomic and ethnic backgrounds to apply for higher education (HE).Students from these underrepresented groups in medical school are referred to as being from a WP background or as WP students.0][11] These initiatives are also employed to educate colleagues trained in areas with lower LSEC rates and less ethnic diversity.Despite these efforts, recent systematic reviews concluded that patients of ethnic minority and LSEC backgrounds were still at higher risk of suffering from dosing errors, complications in care, adverse drug effects and healthcare-associated infections. 6,7In addition to the above initiatives, promoting racial/ethnic/SEC concordant patientclinician interaction has emerged as a possible long-term solution to improving patient outcomes in these groups.Increasing diversity in the medical workforce to better match the diversity of the national population can have many benefits on healthcare; patients feeling more connected with their doctors, increased cultural understanding of patients, less feelings of isolation and increased perspectives among the healthcare team. 124][15] As a result, many medical schools have started WP programs which incorporate contextual admission processes, foundation year programs, and substantial outreach programmes. 16owever, students from these underrepresented backgrounds are more likely to face extra barriers to HE such as lack of support from parents and schools and are more likely to achieve lower A-level grades. 17,180][21] Many WP students had not been given the chance to achieve their full academic potential and were discouraged from applying to HE. 19 Under traditional entry requirements, these students are less likely to receive offers from medical schools.
While the WP student experience at the college level (16-18 years old) is becoming increasingly well-documented, there is less research focusing on the experiences of these students in UK medical schools.Research has shown the initial barriers that WP students face when applying to medical school, do not disappear after admission. 18,19While the work by Basset et al & Brosnan et al focuses on the experiences of first-in-family medical students, it highlights that financial and social barriers may prevent inclusivity of some WP students in the medical school community. 18,19This is supported by findings portraying how WP students find it more difficult to fit in with their peers or identify with staff, 20 making them less likely to ask for support. 22,23In addition to affecting a medical student's sense of belonging in the medical school, these barriers have been shown to affect their studies.Financial worries during medical school, 24 as well as the discrimination faced by BAME students have the potential to impact exam performance. 25BAME students have also shared how they feel pressured to represent their ethnic group in a positive light, a phenomenon known as stereotype threat. 16,23urrent literature informs us of the challenges UK WP students may face such as feeling out of place, struggling financially, and dealing with discrimination, but fails to compare this against non-WP students quantitatively.We aim to fill these gaps in knowledge by further researching what financial, social, and academic challenges WP students face once they are in medical school.This would allow us to see what areas are in most need of addressing.

Research design
This study uses a cross-sectional survey to collect quantitative data using the JISC online questionnaire platform.This questionnaire was disseminated between 11th June 2021 and 8th January 2022.Sample size was calculated as 66 using the qualitative variable equation in case-control studies described by Charan & Biswas. 26There is no data on the prevalence of WP students in medical schools as a whole as opposed to individual characteristics such as socioeconomic status or ethnicity.Therefore data in a previous unpublished study by our group looking into skills on admission to medical school between WP and non-WP students were used to infer prevalence of WP students in the cohort.

Inclusion and exclusion criteria
Participants were only included if they were a current medical or intercalating medical student at one of the medical schools listed in the demographic questions which included all UK medical schools at the time of launching the survey.All other participants were excluded.

Data gathering
The questionnaire was disseminated through the social media channels of the Widening Participation Medic Network (WPMN) on Twitter, LinkedIn, Facebook, and Instagram.It was also distributed by local representatives of WPMN on medical school groups.Distribution messaging in all channels was standardized with a message requesting all medical students regardless of WP status to fill out the questionnaire.

Ethical approval
Ethical approval was sought and approved by Plymouth University-project ID 2712.

Questionnaire design
The questionnaire assessed the WP status of students using WP criteria by merging the different criteria used by each UK medical school.There are 44 quantitative questions spanning 6 domains: WP criteria, financial barriers, social and community barriers, physical and mental health, academic attainment, and response to COVID19-related teaching changes.Questions were derived based on challenges previously identified by medical students. 19,27,28The survey used pre-set answers of Yes or No or a Likert scale.The first page of the questionnaire was a participant information sheet where consent was asked and if participants did not consent then their data will not be included in any analysis and will be deleted.Participants providing consent on the consent page of the questionnaire was considered as informed consent and this method of obtaining informed consent was approved by Plymouth University's Ethics Committee.The last page included a study group email that participants could email to

Data handling and analysis
Results were split into 2 groups: WP student responses and non-WP student responses, using the criteria set from the answers of section 1, of which one criteria needs to be fulfilled to be defined as a WP participant.Groups were compared to see if one group faced a challenge more than the other."Yes and no" data was compared between groups using proportions, odds ratio, and Fischer's exact test.Likert scored questions were analysed using unpaired t-test.

Participant characteristics
One-hundred seventy-six UK medical students participated in this study.There were 97 WP and 79 non-WP students across the UK (Table 1).Sixty-five percent of respondents were in the clinical component of their degrees.Thirty-four percent of the respondents were from a minority ethnic background and 60% were female.

Financial challenges
Participants were asked 8 questions regarding financial barriers (Figure 1).WP students were over twice as likely to feel limited by their financial situation (OR = 2.29, P≤.05), receive financial aid from university or student finance (OR = 2.08, P < .05)rather than parents (OR = 0.44, P≤.05) and have a job impact their studies (OR = 2.53, P ≤.05).There was no significant difference between both groups in receiving enough financial aid (OR = 0.76, P = .57),being aware of how to receive more financial support (OR = 1.22,P = .807)and having a job in medical school (OR = 1.10,P = .86).Forty-six percent of WP students did not receive enough financial aid compared to 32% of non-WP students.Seventy-five percent of WP students had a job during medical school compared to 73% of non-WP students.

Challenges to feeling part of the medical school community
Participants were asked 6 questions about challenges they may have faced in feeling part of the medical school community (Figure 2 and Table 2).There was no significant difference in feeling part of the medical school community between WP and non-WP students (mean = 2.25 vs 2.47, P = .07).WP students were nearly twice as likely to face discrimination at university (OR = 1.98,P = .041)and to not feel represented in the medical school and by the medical workforce (OR = 0.42, P = .005).There was no significant difference between groups in facing discrimination due to sex or gender identity (OR = 1.04,P≥.999), being treated differently to male colleagues (OR = 1.18,WP = .709)and discrimination affecting a student's studies (OR = 1.45,P = .60).

Physical and mental health challenges
Participants were asked 6 questions about challenges they may have faced due to physical and mental health (Figure 3).WP students were more than twice as likely to have their personal background impacting their mental health (OR = 2.65, WP = 0.002).There was no significant differences in students having a disability that impacts life (OR = 0.98, WP≥0.99), facing discrimination due to disability (OR = 0.76, P = .76),experiencing poor mental health (OR = 1.79,P = .11),and feeling supported by the university if they had poor mental health (OR = 1.32,P = .48).There were no students in this cohort who had a visible disability.

Challenges in academic attainment and impact of COVID19-related teaching changes
Participants were asked 6 questions about challenges they may have faced in academia and the impact of COVID19-related teaching changes (Figure 4 and Table 3).There was no significant difference in students receiving enough academic support (OR = 0.60, P = .129),feeling that their pre-medical school background has impacted their performance (OR = 0.95, Ravulapalli et al P≥.99), feeling their grades were affected by COVID19 (OR = 0.84, P = .62),being able to adapt to COVID19-related teaching changes (OR 0.54, P = .089),feeling as though COVID19-related teaching changes put them at a disadvantage (OR = 1.29,P = .43)and confidence in launching an academic project (mean 4.12 (WP) versus 4.2 (non-WP), P = .90).

Financial barriers and work impact
This study presents valuable insight into the WP student medical school experience compared to their non-WP peers.
The domain with the biggest difference in experience were barriers in students' financial situation.WP students were over twice as likely to feel limited by their financial situation, require financial aid, and have their job impact their studies.
Only one study has interviewed students of WP background to understand their experiences with financial hardship in the UK 27 Our study supports the findings by Basset et al, 2019 and identifies these financial hardships are experienced more commonly by WP students nationally. 27The cohort recruited in Basset et al, 2019 include some non-WP participants, therefore we cannot ascertain if these experiences are unique to the WP cohort from that study alone.Our study also identified   Journal of Medical Education and Curricular Development that there was no significant difference between both groups in obtaining a job, however WP students were over twice as likely to feel that having a job would impact their studies.According to Basset et al 2019, students have previously stated that their primary motivation for taking up a job is to provide financial support for their family and to handle the financial instability that accompanies clinical years. 27These reasons may indicate that WP students may be undertaking more work than their non-WP colleagues to undertake larger/more important financial goals.0][31] The nature of extra-curricular job commitments of medical students and particularly those of WP background should be investigated further to understand if additional support needs to be provided to WP students.Increased financial support through bursary or increased loan may be a way to tackle this.

Representation and diversity
A considerable percentage of students in both groups (70% from WP backgrounds vs 49% from non-WP backgrounds) do not feel represented by the medical school or the workforce.However, the proportion of WP students who feel unrepresented is twice as high as their non-WP counterparts.][34] This is a recognized issue and there are initiatives to tackle this which aim to create a more ethnically inclusive medical school society. 35The possible cause behind the higher likelihood of WP students feeling underrepresented, in contrast to their non-WP counterparts, could be due to ethnic underrepresentation.Notably, a significant proportion of students in both groups who felt unrepresented were white British (42% from WP backgrounds and 100% from non-WP backgrounds).Among these white British students, only one was male and heterosexual, while the remaining students identified   themselves as female and/or gay, lesbian, or bisexual.Lack of recruitment of women to senior medical school roles has long been identified as an issue.A recent quantitative study identified that within London medical schools there was no significant difference between the proportion of women in the student body and in the leadership positions. 34,36,37In our cohort, no heterosexual female student who felt unrepresented was from a London university.This may suggest that universities outside of London do not have a similar presence of women in the faculty, there may be other reasons this student body do not feel represented or that it is in the medical workforce they feel underrepresented in.The NHS medical workforce is represented in proportion or overrepresented to the national population by South Asian, black and British white ethnicities and underrepresented by east Asian ethnicities.Only 47% (16 of 34 students from south Asian ethnicity) and 9% (1 of 11 students from black, African, Caribbean or black British ethnicity) felt represented from our study.This could suggest that these students felt they were not represented at the medical school level or that the student had not seen representation due to their geographical location.

Discrimination and racial harassment
Our study reported WP students were nearly twice as likely to face discrimination than non-WP students, however there was no difference in the likelihood of being discriminated against due to sex or gender identity.This is likely due to race as there was no difference in WP students facing discrimination due to sex or gender identity compared to their non-WP colleagues.This further reinforces the findings of recent reports by BMJ and BMA that highlighted the issue of racial harassment, discrimination, and bullying experienced by many ethnic minority students, with insufficient actions taken by medical schools to address it. 38A recent project by Lynn et al suggests that student led initiatives to raise awareness of discrimination such as racism and inspiring confidence to advocate against it may be a more effective method than traditional faculty/ school led approaches. 39cial integration and mental health WP students in our cohort on average felt only slightly less part of the medical school community compared to the non-WP cohort, with no significant difference.Although evidence of WP students finding difficulty in establishing social networks exists throughout the literature, another common theme that emerges is that WP students find strong social connections with individuals from similar backgrounds-as identified by Krstic et al. 22 With medical schools placing more significance on WP programs and receiving increased applications, it is hoped that the situation will improve for WP students in this regard.
Although no significant difference between having or facing discrimination due to mental or physical health and disability was seen between groups, WP students were 2 times more likely to have mental health impacted by personal background.Adverse mental health among medical students is unfortunately common with over 1 in 5 students receiving a formal diagnosis last year and many more suffering from bouts of emotional stress. 40The cause of the emotional stress can be complex, compounded by several factors. 41Much of the current literature attributes much of the adverse mental health seen in medical students to the medical course, however it may be the case that the etiology of adverse mental health may be different in WP students due to different socioeconomic and cultural backgrounds.A review recently looked into the mental well-being of black university students in the UK and highlighted themes of institutional racism and culture shock as contributing factors towards adverse mental health in these students. 42This review did not use any studies with students in medical school, and there is no such research for students of other nonwhite ethnicities or of those medical students coming from a low socioeconomic background.Further investigation through focused interview study is needed into the mental health of the different WP medical student groups to improve pastoral care programs offered by institutions.

Academic support and COVID-19 adaptation
While no statistical significance was reached, our results suggest that there still may be a link between WP students and a sense of not receiving enough academic support at medical school.According to Curtis & Smith, 31 students on a gateway course, which mostly comprised students from a lower socioeconomic background (excluding those from Kings College London, where the proportion of students from a lower socioeconomic background is unclear), performed comparably on medical school exit exams to students on traditional courses when their UCAT and A-Level scores were taken into account.Many of these students were also from a BAME background.However, the comparability in performance was only observed after controlling for A-Level and UCAT scores on admission.It would be interesting to examine whether this pattern holds for WP students on traditional courses, as prior data indicates that certain WP groups, such as ethnic minority students, have shown lower performance in undergraduate and postgraduate exams across various exam formats. 43Intake of students in gateway medical courses is increasing however many WP students are admitted in traditional courses where there may not be as many individuals from similar backgrounds to form friendships and learn with.Our results and previous evidence suggest this topic is still not well understood.While the findings of this study did not reach statistical significance, there were suggestive trends indicating that WP students may have faced relatively greater challenges in adapting to the 6 Journal of Medical Education and Curricular Development changes brought about by COVID-19 in teaching methods.The P-value of .09points towards this potential trend.A study of 2721 medical students found that barriers to online teaching included poor internet connections, distractions from family, and lack of space, which may be particularly challenging for students from low SES backgrounds with family responsibilities. 44Understandably, both student group felt their grades were impacted by the pandemic however further investigation through focused interview studies can reveal if WP students may need further support to adapt to online teaching.

Limitations
There are several limitations to this study approach.While efforts were made to disseminate the survey widely, this studies sample size of 176 students may not fully represent the diverse range of experiences among medical students in the United Kingdom.The data is self-reported without elaboration of why the answers, which may introduce recall bias or participants providing responses they deemed socially acceptable.There is also the possibility of response bias which may impact the representativeness of the sample and the generalizability of the findings to the wider medical student population.Additionally, the survey used in this study is not validated as no previous validated survey exists for this use and it was not pilot-tested.

Conclusion
Our findings suggest that WP students have a distinct experience during their time in medical school in comparison to their non-WP peers.In order to gain a more comprehensive understanding of the issues faced by WP students, further investigation through qualitative studies is required.Specifically, it is important to explore areas such as financial experiences, discrimination, mental health, and academic support received by WP students.
Collaboration between educational institutions, policymakers, and medical professionals stands as a pivotal pathway for implementing effective changes.These changes, informed by qualitative insights, can pave the way for a medical education system that ensures equal opportunities for every student, irrespective of their background.As we advance towards a more equitable future, understanding the experiences of WP students is not only essential for their success but also integral to advancing the quality of medical education as a whole.

2
Journal of Medical Education and Curricular Development opt-out or ask further questions.The survey used can be seen in Supplemental material.

Figure 1 .
Figure 1.Odds ratio forest plots for financial barriers faced by WP students compared to non-WP students.

Figure 2 .
Figure 2. Odds ratio forest plots for medical school community challenges faced by WP students compared to non-WP students.

Figure 3 .
Figure 3. Odds ratio forest plots for physical and mental health challenges faced by WP students compared to non-WP students.

Figure 4 .
Figure 4. Odds ratio forest plots for academic self-perception and COVID19-related teaching challenges by WP students compared to non-WP students.

Table 1 .
Participant characteristics of medical student cohort.

Table 2 .
Likert scale scoring between WP and non-WP students on how much they feel a part of the medical school community.Not at all part of the community-1 (%) Slightly part of the community-2 (%) Part of the community -3 (%) Very much part of the community-4 (%)

Table 3 .
Likert scale scoring between WP and non-WP students on how confident they feel in launching an academic project (1 = not confident at all, 10 = completely confident).